Thursday, April 27, 2017

It’s BACK—the terrible, horrible, no good, very bad bill to
repeal and replace the Affordable Care Act (ACA). Last month, I
blogged about how the bill, called the American Health Care Act, was the
worst legislation for health care of any that I have seen in 38 years of
advocacy for doctors and patients. While
it was good that this bill was pulled by House Speaker Paul Ryan on March 24
due to a lack of support among Republican
lawmakers, he may bring it back for a vote as early as this Friday, April 28.
Only, this time, believe it or not, with changes designed to win support from
hard-right conservatives that make the original bill even worse for
patients. I guess we will have to call
this version the even more terrible,
horrible, no good, very bad, bill for patient care.

On Tuesday, ACP was able to confirm that the House GOP
leadership and Trump administration were close to reaching a deal with 20 or so
of the most conservative lawmakers, the self-described “Freedom Caucus.”
Unfortunately, as explained in a
detailed letter that we sent to all members of Congress later that day, the
proposed “compromise” would gut existing
law protections for people with preexisting medical conditions and requirements
that insurers cover essential benefits by allowing states to opt-out of such
requirements. And today, we joined in a
coalition letter with 5 other physician membership organizations,
collectively representing over 560,000 physician and medical student members,
expressing our combined opposition to the “compromise” bill.

Let me be clear why the compromise makes a terrible bill
even worse:

It would allow states to obtain “waivers” to opt-out of the
ACA’s prohibition on insurers charging more to people with preexisting
conditions. That’s right, the
“compromise” would return us to the pre-ACA days when states often allowed
insurers to charge whatever they wanted to people with conditions like asthma,
diabetes or dozens of other conditions that were considered to be “declinable”
by insurers. As ACP explained in its letter to Congress, “Before the ACA, insurance plans sold in the individual
insurance market in all but five states typically maintained lists of so-called
"declinable" medical conditions—including asthma, diabetes,
arthritis, obesity, stroke, or pregnancy, or having been diagnosed with cancer
in the past 10 years. Even if a revised bill would not explicitly repeal the
current law’s guaranteed-issue requirement—which requires insurers to offer
coverage to persons with pre-existing conditions like these—guaranteed issue
without community rating allows insurers to charge as much as they believe a
patient’s treatment will cost. The result would be that many patients with
pre-existing conditions would be offered coverage that costs them thousands of
dollars more for the care that they need, and in the case of patients with
expensive conditions like cancer, even hundreds of thousands more.”

The bill does say that states would have to set up or participate
in high risk pools for people with preexisting conditions in order to be
approved for a waiver. But we know from
experience that underfunded high-risk pools, which were common before the ACA,
typically had very high premiums and deductibles, long wait lists, and limited
benefits, making the coverage unaffordable for those who need it most. And the
amended AHCA does not provide anywhere near the amount of money that could make
high risk pools viable, and does not set any standards or funding levels that
states must meet to ensure that coverage under the pools are affordable and
benefits are adequate.

It would allow states to obtain “waivers” to opt-out of the
ACA’s requirement that all insurers cover 10 categories of essential medical
care services. We know from the pre-ACA
days what this could mean for patients: in many states, insurers will once
again be allowed to decline coverage of needed benefits like physician and
hospital visits, maternity care and contraception, mental health and substance
use disorder treatments, preventive services, and prescription drugs. “Prior to
passage of the ACA, 62% of individual market enrollees did not have coverage of
maternity services, 34% did not have substance-use disorder services, 18% did
not have mental-health services and 9% did not have coverage for prescription
drugs,” ACP
wrote to Congress. “A recent
independent analysis found that the AHCA’s repeal of current law required
benefits would result in patients on average paying $1,952 more for cancer
drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung
diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient
admission for mental health; $4,555 for inpatient admission for substance use
treatment; and $8,501 for maternity care. Such increased costs would make it
practically impossible for many patients to avail themselves of the care they
need. The result will be delays in getting treatment until their illnesses
present at a more advanced, less treatable, and more expensive stage, or not
keeping up with life-saving medications prescribed by their physicians.”

And repeal of the essential benefit requirements would mean
that insurers would no longer be required to cover substance use disorder
treatments. “Allowing states to
eliminate the [Essential Health Benefits] will threaten our nation’s fight
against the opioid epidemic,” ACP told Congress. “A study concluded that with
repeal of the ACA, ‘approximately 1,253,000 people with serious mental
disorders and about 2.8 million Americans with a substance use disorder, of
whom about 222,000 have an opioid disorder, would lose some or all of their
insurance coverage.’”

And the “compromise” would even gut the ACA’s ban on
insurers imposing annual or lifetime limits on coverage, because under current
law insurers are only banned from imposing dollar limits on services that are
included in the mandatory essential health benefits package. If a state, for example, decided that
chemotherapy was no longer an essential benefit in your state, there would be
nothing stopping insurers from putting a $100,000 lifetime dollar limit (if
even that much) on coverage for your cancer treatment. After that, sorry, you’d be on your own,
forcing choices like lose your house, or lose your health care, you
decide.

The bill’s gutting of prohibition on annual and lifetime
coverage limits would affect not only people who get coverage through health plans sold through the ACA’s
marketplaces, but also the vast majority of people who get coverage from their
employer, as analyst Tim Jost explains today in a Health
Affairs blog. “Since the ACA’s
prohibitions of lifetime and annual limits and cap on out-of-pocket
expenditures also only apply to essential health benefits, states granted a
waiver would be able to define these protections as well. The changes to the
lifetime and annual limits and to the out-of-pocket caps could potentially
apply as well to large group and self-insured employer plans.” Jost also
observes that although the amendment says that “’nothing in this Act shall be
construed as permitting insurers to limit access to health coverage for
individuals with preexisting conditions,” but that is precisely what health
status underwriting [which could return in states that obtain waivers] does.
Health status underwriting could effectively make coverage completely
unaffordable to people with preexisting conditions.”

And remember, even before the proposed compromise made the
AHCA even worse, the original bill was unacceptable because it cut, capped, and
block granted Medicaid, ended funding for Medicaid expansion, and replaced the
ACA’s income-based premium and cost-sharing subsidies with regressive age-based
ones that would make premiums and deductibles unaffordable for older and sicker
patients, resulting in 24 million more uninsured persons, according to the
Congressional Budget Office.

So if politicians tell you that people with preexisting
conditions are protected by the amended AHCA, don’t believe them. They are either lying, or more charitably,
don’t understand what is being proposed.
And if they say premiums will be lower, keep in mind that while this
might be true for some young and healthy people, it would be at the expense of
making health care unaffordable for older and sicker patients.

Yet Speaker Ryan is counting votes right now in the hope of
bringing the bill to a vote by Friday so it can be passed by the House of
Representatives during President Trump’s first 100 days.

Don’t let Speaker Ryan and President Trump bring their even
more terrible, horrible, no good, very bad bill back from the dead. Call your member of Congress today,
especially if he or she is a moderate
Republican or one in a competitive district, at 202-224-3121 and help us
put a nail in the AHCA’s coffin. (And
even if you have called before, they need to hear from you again). Don't put this off, tomorrow could be too
late. Patients are depending on you.

Today’s question: did you make your call to Congress to urge
them to vote no on the even more terrible, horrible, no good, very bad AHCA!